Of Pediatric Trauma

Of Pediatric TraumaOf Pediatric TraumaOf Pediatric Trauma

Mike Schmit, M.D., FACS, FASMBS

Medcenter One

Bismarck, ND

Mike Schmit, M.D., FACS, FASMBS

Medcenter One

Bismarck, ND

The Problem….

� “Trauma is the leading cause of morbidity and mortality in the US pediatric population”

� 20,000 die each year

◦ For every death - 40 hosp, and 1120 treated in ER

� 50,000/yr acquire permanent disabilities

�Most secondary to blunt mech

History

� Peter Kottmeier 1962

� Resources for Optimal Care of the Injured Patient – ACS, 1976

�NPTR, 1985

� 81 accredited Pediatric centers

� Jan 14, 2010 – AAP

◦ www.healthychildren.com

Kids….The differenceKidsKids…….The difference.The difference

� Should not be treated as “little adults”◦ Anxiety, unfamiliar individuals and surroundings

� Respond differently

� Less body fat, smaller body mass, more elastic connective tissue

� Close approximation of internal organs combined with a very pliable skeletal structure

� Should not be treated as “little adults”◦ Anxiety, unfamiliar individuals and surroundings

� Respond differently

� Less body fat, smaller body mass, more elastic connective tissue

� Close approximation of internal organs combined with a very pliable skeletal structure

Kids….The differenceKidsKids…….The difference.The difference

�Hypothermia�� The injured child’s vicious enemy◦ Bair Huggers/ Heat lamps

◦ Trauma Bay �� >80 - 85 degrees

◦ Fluid warmers…

� Children under 4 yrs of age◦ Increased metabolic rate

◦ O2 demand 2X greater than adults

◦ “Secondary injury”

�Hypothermia�� The injured child’s vicious enemy◦ Bair Huggers/ Heat lamps

◦ Trauma Bay �� >80 - 85 degrees

◦ Fluid warmers…

� Children under 4 yrs of age◦ Increased metabolic rate

◦ O2 demand 2X greater than adults

◦ “Secondary injury”

Kids….The DifferenceKidsKids…….The Difference.The Difference

� Children are resilient, however…

◦ The period of “meta stability”decreases with age

◦ Some describe the “platinum half-hour”

� Case in point…

◦ If presenting with hypotension, 30% of blood volume has been lost

� Your already way behind…

� Children are resilient, however…

◦ The period of “meta stability”decreases with age

◦ Some describe the “platinum half-hour”

� Case in point…

◦ If presenting with hypotension, 30% of blood volume has been lost

� Your already way behind…

Primary SurveyPrimary SurveyPrimary Survey

� ABCDE’s – Same priorities

� Inadequate ventilation remains the single most common cause of cardio-respiratory arrest in the injured child

◦ Secure airway expediently

◦ Proper equipment ready and functional

◦ Broselow?

� ABCDE’s – Same priorities

� Inadequate ventilation remains the single most common cause of cardio-respiratory arrest in the injured child

◦ Secure airway expediently

◦ Proper equipment ready and functional

◦ Broselow?

Gastric DistentionGastric Distention

� Children depend more on diaphragmatic excursion

� NG decompression essential

� Reduce aspiration

Intubation - PediatricIntubation Intubation -- PediatricPediatric

� DAI plus…

◦ Atropine (0.1-0.5 mg)

◦ Cardiac output is RATE dependent –The ability to increase stroke volume is very limited

◦ Vagal response, dries secretions

� Placement

◦ ET tip at sternal notch

◦ Depth(CM)=0.5(age) + 12

� DAI plus…

◦ Atropine (0.1-0.5 mg)

◦ Cardiac output is RATE dependent –The ability to increase stroke volume is very limited

◦ Vagal response, dries secretions

� Placement

◦ ET tip at sternal notch

◦ Depth(CM)=0.5(age) + 12


� Tube size estimation◦ Nail of 5th digit

◦ >2yrs�� (16 + age)/4

�Under 8 years of age, use uncuffedtube◦ Cricoid ring acts as a physiological “cuff”

� Avoid excess cricoid pressure ◦ May cause airway to collapse

� Tube size estimation◦ Nail of 5th digit

◦ >2yrs�� (16 + age)/4

�Under 8 years of age, use uncuffedtube◦ Cricoid ring acts as a physiological “cuff”

� Avoid excess cricoid pressure ◦ May cause airway to collapse


� Prone to bronchial intubation◦ Infant 4 to 5 cm

◦ Child 7 to 8 cm

� Narrow airway prone to obstruction◦ Relatively large tongue and debris

◦ Secretions

� Very anterior and superior larynx

� Large epiglottis (“Omega”)

� Smallest diameter at cricoid ring – Not the vocal cords

� Be aware – Dislodged ET tube

� Prone to bronchial intubation◦ Infant 4 to 5 cm

◦ Child 7 to 8 cm

� Narrow airway prone to obstruction◦ Relatively large tongue and debris

◦ Secretions

� Very anterior and superior larynx

� Large epiglottis (“Omega”)

� Smallest diameter at cricoid ring – Not the vocal cords

� Be aware – Dislodged ET tube

Adult – Pediatric Airway

Surgical Pediatric AirwaySurgical Pediatric AirwaySurgical Pediatric Airway

� Needle jet insufflation◦ 12 to 16 gauge needle

◦ Oxygenation, NOT ventilation

◦ Temporary

� Surgical cricothyroidotomy◦ Reserved for >8 yrs

◦ Infants/Children �� high risk of damage

� Percutaneous◦ Gaining acceptance….

� Needle jet insufflation◦ 12 to 16 gauge needle

◦ Oxygenation, NOT ventilation

◦ Temporary

� Surgical cricothyroidotomy◦ Reserved for >8 yrs

◦ Infants/Children �� high risk of damage

� Percutaneous◦ Gaining acceptance….

Ventilation - Pediatric

� Remember rates differ

� Bag mask devices – pediatric

◦ Iatrogenic barotrauma

�Hypoxia – Number one cause of cardiac arrest in the child

�High index of suspicion

◦ Mediastinum very mobile

◦ Simple pneumothorax…

� Remember rates differ

� Bag mask devices – pediatric

◦ Iatrogenic barotrauma

�Hypoxia – Number one cause of cardiac arrest in the child

�High index of suspicion

◦ Mediastinum very mobile

◦ Simple pneumothorax…

Venous Access - PediatricVenous Access Venous Access -- PediatricPediatric

� Usually the most difficult procedure◦ Hypotension/hypovolemia

◦ Landmarks obscured

� ATLS suggests two attempts ◦ 90 seconds

� Intraosseous (Children <6yrs)◦ EZ IO

◦ Temporary (4 to 6 hours)

◦ Large volumes safe (100ml/min)

◦ All resuscitative drugs, blood products safe

◦ Never place distal to fractures

� Usually the most difficult procedure◦ Hypotension/hypovolemia

◦ Landmarks obscured

� ATLS suggests two attempts ◦ 90 seconds

� Intraosseous (Children <6yrs)◦ EZ IO

◦ Temporary (4 to 6 hours)

◦ Large volumes safe (100ml/min)

◦ All resuscitative drugs, blood products safe

◦ Never place distal to fractures

Intraosseous PlacementIntraosseousIntraosseous PlacementPlacement

� 2 CM below tibialtuberosity

� 3 CM above femoral condyle

� 4 to 6 hours

◦ Establish venous access

� E-Z IO

� 2 CM below tibialtuberosity

� 3 CM above femoral condyle

� 4 to 6 hours

◦ Establish venous access

� E-Z IO

Venous Access - PediatricVenous Access Venous Access -- PediatricPediatric

� Venous cutdown(Children >6yrs)

◦ Ankle

◦ Groin

◦ Basilic vein

◦ External jugular

� Central approach

� Venous cutdown(Children >6yrs)

◦ Ankle

◦ Groin

◦ Basilic vein

◦ External jugular

� Central approach

Pediatric Injuries: Some DifferencesPediatric Injuries: Pediatric Injuries:

Some DifferencesSome Differences

Intracranial InjuryIntracranial InjuryIntracranial Injury

� CNS – Most commonly injured system

� Common in children <12 months◦ Most vulnerable <3 months

� Early recognition and resuscitation◦ SBP >80mm Hg

◦ Hypotension�� The single most common cause of secondary injury

◦ O2 Saturation >95%

� Implement ICP early (Esp if GCS <8)

� Ventriculostomy�� Immediate response

� CNS – Most commonly injured system

� Common in children <12 months◦ Most vulnerable <3 months

� Early recognition and resuscitation◦ SBP >80mm Hg

◦ Hypotension�� The single most common cause of secondary injury

◦ O2 Saturation >95%

� Implement ICP early (Esp if GCS <8)

� Ventriculostomy�� Immediate response


� Subdural hematomas◦ Common with infants and adolescents

◦ Mortality up to 35 – 40%

� Epidural hematomas◦ Uncommon in children <4 yrs of age

◦ Risks increases with progression through childhood

◦ Mortality 4 – 5%

� Subdural hematomas◦ Common with infants and adolescents

◦ Mortality up to 35 – 40%

� Epidural hematomas◦ Uncommon in children <4 yrs of age

◦ Risks increases with progression through childhood

◦ Mortality 4 – 5%


� Elevated ICP in children◦ >15mm Hg in a child <6yrs

◦ >20mm Hg in a child >6yrs

◦ Both lasting more than 15 minutes

� Critical value of CPP is >50mm Hg

� ICP should be kept <20

�Hyperventelation?◦ Hypocapnic induced vasoconstriction

� Early CT scanning

� Elevated ICP in children◦ >15mm Hg in a child <6yrs

◦ >20mm Hg in a child >6yrs

◦ Both lasting more than 15 minutes

� Critical value of CPP is >50mm Hg

� ICP should be kept <20

�Hyperventelation?◦ Hypocapnic induced vasoconstriction

� Early CT scanning


� Mannitol (0.25 mg/kg) �� Reduces pressure within 15 minutes◦ May repeat 4 times to osmolarity of 310 to 320 mOsm

� Lasix (1mg/kg) �� Also decreases CSF � Post traumatic seizures common in children◦ Dilantin (10 mg/kg), Lidocaine (1mg/kg)◦ Give early in resuscitation �� Neuroprotective

� Avoid seizures and fever!◦ Increased metabolic demand◦ “Secondary injury”

� Mannitol (0.25 mg/kg) �� Reduces pressure within 15 minutes◦ May repeat 4 times to osmolarity of 310 to 320 mOsm

� Lasix (1mg/kg) �� Also decreases CSF � Post traumatic seizures common in children◦ Dilantin (10 mg/kg), Lidocaine (1mg/kg)◦ Give early in resuscitation �� Neuroprotective

� Avoid seizures and fever!◦ Increased metabolic demand◦ “Secondary injury”

Spinal Cord InjurySpinal Cord InjurySpinal Cord Injury

�Uncommon (<2% injured children)

� Vehicular Crashes

�Only 1/3 with cervical bony injuries will have neurologic injury

◦ Only ½ of these have radiographic findings (J Pediatric Surgery 2001)

� Immobilization

�Uncommon (<2% injured children)

� Vehicular Crashes

�Only 1/3 with cervical bony injuries will have neurologic injury

◦ Only ½ of these have radiographic findings (J Pediatric Surgery 2001)

� Immobilization

Clearing ImmobilizationClearing ImmobilizationClearing Immobilization

� Clinical clearance◦ No midline cervical tenderness

◦ No distracting injuries

◦ Alert, no intoxication

◦ No neurological deficits

� Cross table lateral �� 85% Sensitivity◦ Technique difficult

� CT Scan?

� Re-examination �� DOCUMENT!!

� Any question…keep immobilized

� Clinical clearance◦ No midline cervical tenderness

◦ No distracting injuries

◦ Alert, no intoxication

◦ No neurological deficits

� Cross table lateral �� 85% Sensitivity◦ Technique difficult

� CT Scan?

� Re-examination �� DOCUMENT!!

� Any question…keep immobilized

Spinal Cord InjurySpinal Cord InjurySpinal Cord Injury

� SCIWORA

◦ Present with brief sensory or motor deficits

◦ Progress to severe neurological deficit over next 4 hours (J Neurosurgery 1988)

� Due to extreme ligamentous laxity

◦ Cord (0.5cm), and vertebra (2cm)

◦ Age 0-2 �� Very flexible (2cm)

◦ Age 2-8 �� More restricted (1-2cm)

◦ Age >8 �� Similar to adult distraction

� Pseudosubluxation

� SCIWORA

◦ Present with brief sensory or motor deficits

◦ Progress to severe neurological deficit over next 4 hours (J Neurosurgery 1988)

� Due to extreme ligamentous laxity

◦ Cord (0.5cm), and vertebra (2cm)

◦ Age 0-2 �� Very flexible (2cm)

◦ Age 2-8 �� More restricted (1-2cm)

◦ Age >8 �� Similar to adult distraction

� Pseudosubluxation

SCIWORASCIWORASCIWORA

Thoracic Injuries - PediatricThoracic Injuries Thoracic Injuries -- PediatricPediatric

� Not common – high mortality

� 2ndmost common cause of death

� Pliable rib cage and increased mediastinalmobility

� 85% due to vehicular mechanisms

� 20% will require intubation

◦ Usually to treat CNS injury

◦ Pulmonary contusion

� Most injuries treated same as in adult

� Not common – high mortality

� 2ndmost common cause of death

� Pliable rib cage and increased mediastinalmobility

� 85% due to vehicular mechanisms

� 20% will require intubation

◦ Usually to treat CNS injury

◦ Pulmonary contusion

� Most injuries treated same as in adult


� Main injuries seen in the child include pulmonary contusions and hematomas

� Ribs very pliable◦ Mult fractures �� Keep in mind intentional abuse

◦ “More than 2 less than 2”

� Traumatic asphyxia and tracheobronchial injury more common than◦ Pneumothorax

◦ Aortic rupture

◦ Flail chest

� Petechiae/Hemorrhage across face, neck, upper chest, conjunctiva◦ Abrupt retrograde high pressure in SVC

� Main injuries seen in the child include pulmonary contusions and hematomas

� Ribs very pliable◦ Mult fractures �� Keep in mind intentional abuse

◦ “More than 2 less than 2”

� Traumatic asphyxia and tracheobronchial injury more common than◦ Pneumothorax

◦ Aortic rupture

◦ Flail chest

� Petechiae/Hemorrhage across face, neck, upper chest, conjunctiva◦ Abrupt retrograde high pressure in SVC


� Recognition may be elusive

◦ 2/3 of children will present to ED with stable vital signs

� Thoracotomy rare, indications remain:

◦ Massive bleeding

◦ Massive air leak

◦ Cardiac tamponade

◦ Penetrating trauma, no vital signs in ER

� High index of suspicion for other injuries

� Recognition may be elusive

◦ 2/3 of children will present to ED with stable vital signs

� Thoracotomy rare, indications remain:

◦ Massive bleeding

◦ Massive air leak

◦ Cardiac tamponade

◦ Penetrating trauma, no vital signs in ER

� High index of suspicion for other injuries

Abdominal Injuries - PediatricAbdominal Injuries Abdominal Injuries -- PediatricPediatric

� Penetrating injuries rare

◦ Involve small intestine usually

◦ Treated with adult protocols

◦ Incidence increasing

� Blunt more common

◦ 90% children with abdominal injuries

◦ Generally liver and spleen

◦ Overall mortality �� <5%

◦ For abuse/assault victims �� 12.5%

� Penetrating injuries rare

◦ Involve small intestine usually

◦ Treated with adult protocols

◦ Incidence increasing

� Blunt more common

◦ 90% children with abdominal injuries

◦ Generally liver and spleen

◦ Overall mortality �� <5%

◦ For abuse/assault victims �� 12.5%


� Rib cage small, cannot provide adequate protection

◦ Liver, spleen, kidneys vulnerable

� Pelvis small – Bladder an intra-abdominal organ

�Undeveloped abdominal musculature

� Rib cage small, cannot provide adequate protection

◦ Liver, spleen, kidneys vulnerable

� Pelvis small – Bladder an intra-abdominal organ

�Undeveloped abdominal musculature


� Diagnosis can be very difficult◦ Distracting injuries

◦ Unfamiliar surroundings

◦ Intense anxiety from separation

� Most injuries treated non-operative◦ Began in 1960’s (Shaftan)

◦ By 1970 (Adhesive SBO after negative Lap)� Mortality 1.6%

� Morbidity 19%

� Re-admission rate 3%

� Diagnosis can be very difficult◦ Distracting injuries

◦ Unfamiliar surroundings

◦ Intense anxiety from separation

� Most injuries treated non-operative◦ Began in 1960’s (Shaftan)

◦ By 1970 (Adhesive SBO after negative Lap)� Mortality 1.6%

� Morbidity 19%

� Re-admission rate 3%


� OPSS

◦ 1.5% of splenectomized children

◦ 50 fold increase in mortality from septicemia

◦ Greatest in first 2 years after splenectomy

◦ Children <5 yrs of age

� Should receive daily antimicrobial prophylaxis

� Splenic anatomy

◦ Thick fibrous capsule

◦ >95% salvage rate (Pediatric centers)

� OPSS

◦ 1.5% of splenectomized children

◦ 50 fold increase in mortality from septicemia

◦ Greatest in first 2 years after splenectomy

◦ Children <5 yrs of age

� Should receive daily antimicrobial prophylaxis

� Splenic anatomy

◦ Thick fibrous capsule

◦ >95% salvage rate (Pediatric centers)


� Splenic injury observation

◦ 77% grade 1 and 2 injuries will show radiographic resolution in 6 weeks

◦ 8 - 20% for grade 3 to 5

◦ Recommend 4 to 7 day hospital stay

� Repeat CT?

◦ 3 weeks “quiet” activity �� home

◦ Full activity �� 3 months post injury

◦ No CT if doing well clinically

◦ Delayed failure?

� First 12 to 24 hours most common

� Splenic injury observation

◦ 77% grade 1 and 2 injuries will show radiographic resolution in 6 weeks

◦ 8 - 20% for grade 3 to 5

◦ Recommend 4 to 7 day hospital stay

� Repeat CT?

◦ 3 weeks “quiet” activity �� home

◦ Full activity �� 3 months post injury

◦ No CT if doing well clinically

◦ Delayed failure?

� First 12 to 24 hours most common


� Intervention of spleen injury

◦ Close monitoring/frequent exam

◦ Require transfusion of more than half of their blood volume (40ml/kg) within 24 hours

◦ Hemodynamic stability is the key

� Intervention of spleen injury

◦ Close monitoring/frequent exam

◦ Require transfusion of more than half of their blood volume (40ml/kg) within 24 hours

◦ Hemodynamic stability is the key


� Concept now applied to liver and renal trauma◦ Portal vein, hepatic veins, and SVC intact

� Pancreas remains controversial◦ Verified ductal injury� Drainage

� Resection (Distal)

� Splenic preservation remains important

� Will tolerate up to 75% distal resection

� Concept now applied to liver and renal trauma◦ Portal vein, hepatic veins, and SVC intact

� Pancreas remains controversial◦ Verified ductal injury� Drainage

� Resection (Distal)

� Splenic preservation remains important

� Will tolerate up to 75% distal resection

Liver/Renal Trauma - Peds

“Seat-Belt” Sign““SeatSeat--BeltBelt”” SignSign

� Impact usually severe

� Small bowel, stomach, colon, lumbar spine, pancreas, mesentery

� Initial imaging negative

◦ Potential for injury remains high

� Impact usually severe

� Small bowel, stomach, colon, lumbar spine, pancreas, mesentery

� Initial imaging negative

◦ Potential for injury remains high

“Handlebar Injury”

� Small bowel/duodenum

� Pancreatic injury

Air BagsAir BagsAir Bags

� Air bag morbidity/mortality

�Mechanisms

◦ Proximity to bag

◦ Can cause SCIWORA

◦ Basilar skull fractures

� Deploy at 150 mph

◦ Second generation

� Air bag morbidity/mortality

�Mechanisms

◦ Proximity to bag

◦ Can cause SCIWORA

◦ Basilar skull fractures

� Deploy at 150 mph

◦ Second generation

SummarySummarySummary

� Head injury remains most significant cause of morbidity and mortality

� Critically injured children must be kept normothermic

� Observational treatment

� Essential to avoid hypovolemicshock

� Avoid “secondary” injury

� Head injury remains most significant cause of morbidity and mortality

� Critically injured children must be kept normothermic

� Observational treatment

� Essential to avoid hypovolemicshock

� Avoid “secondary” injury

SummarySummarySummary

� Care of the injured child is a complex process – which differs from the adult population

� ABCDE’s - ATLS

� High level of suspicion

� Occult injuries

� Intentional abuse

� The single most important take home point remains �� Prevention

� Care of the injured child is a complex process – which differs from the adult population

� ABCDE’s - ATLS

� High level of suspicion

� Occult injuries

� Intentional abuse

� The single most important take home point remains �� Prevention

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Of Pediatric Trauma

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